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2-0d—1999 4:.11 Pl,i FROM <br /> P. 6 <br /> SAN JOAQUIN COUNrI PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALiH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALL4TION PERMIT <br /> THE APPt,.CiT.CN FOR INSTALLATION OF MERGROUND STCRACc TANKS IS ONLY VALID FCR THE CAL—SWAR YEAR IN uHI0 IT NAS SEE!7 ISSUED, <br /> ,A PSRMIT MAY 3E EXTENDED INTO THE NEXT CALE14CAR YEAR IF A LPTTcR IS SENT TO P4S-5M RECUESTiNG THIS JITEHSICM THIRTY DAYS <br /> PRIOR 70 raE -'NO OF THE CAL:,NQAR YEAR- A "CNE TIME, ONE YEAR :NSICN MAY 3E Mt"TED BY PHS-VFIO UPCN RE'.IPT OF THIS LETTER- <br /> DO NOTDR i i z IN ANY SHADED AREAS- <br /> I EPA SITE x 1 PRC.:ECT --%TACT & 7ELEP40ME <br /> FACILITY NAME <br /> C I ADDRESS <br /> C20SS STREET <br /> D4NERJOPSAAT02 PHONE 0 <br /> C CONTRACTOR NAME I PIic�E <br /> J ADDRESS L x t c.ass <br /> T z_-> I <br /> f R HAZARDOUS 'JAST'c C£siT i F I Eta YES_�C NOi XSRt..C�Ip.x 0 C <br /> A <br /> IIII T FIRE OISTRICT ��u��ryt� Pso17 j. <br /> 1 0 ! 30ARD OF EQUALi2ATICN t I i <br /> R <br /> � i1llIli111tlIIlillllil1111111i - <br /> 'ANX ID TANK SIZE i CHEMICALS 70 3E STORED PROPOSED INSTALLATiCN <br /> 8�1 <br /> ' � t <br /> a <br /> 39- <br /> 39- <br /> 39- <br /> I IfI <br /> 9-39- <br /> 39- <br /> ilii <br /> L APPROVE: APPROVED 'JM. CCUDITIOH(S) OISAPPRMS <br /> N ?LAN REVIEWERS NAME CSE; EI <br /> A7ACHMT ATH COND(TICHS) OA`` <br /> � ,il11I1lf1I1[l11If1l1 I1 1 ltillltflflfllf 1if111l11i11l1lil ! il1 itilllittfUtl 1111illltl <br /> APPLICANT MUST AERFCRM ALL '4RX tN ACC=ANCZ 'JITH SAN 'QAQUIN =LINTY =19ANC`S, STATE LAWS, ANO RULES AND RE'"a„'LATIONS OF <br /> SAN JCAOUIN COUNTY PUBLIC WEALTH SiRVICES. GWMa OR LICENSE'l. ACaT'S SIGNATURE CMIFIES THE FOLLOVING: "I CERTIFY THAT IN f <br /> rHE PERFORMANCE OF THE YORK FCR DNF ERMIT IS ISSUED, I SHALL RIOT EMPLOY AMY PER= FN SUCH A MAYNER AS TO 3ECCME <br /> f SUBJECT TO tMRKER'S CGMP ATIOIt {!S OF CAL FORNIA." CCNTRAC,='S TIRING CR %OCUTRAC:IHG SIGMATME MMFIES THE FcLLCWlMG:j <br /> "I CtR'IFY raAT IN THE ER C OF IHE ' FOR 14HIC:i THIS PERMIT IS ISSUED, I SHALL E14PLCY PERSONS SLEWELi TO �:r17tKEMS f <br /> CCMPENSATION LAWS OF LIF ; <br /> r <br /> APP!.CANT'S SIGNATURE:[rl TITLE A w � OAT—. <br /> I <br /> Indic3te he resoansibie par,-:y _0 ae hilted `or acditionaL PHS-"- o Stasi time experoded beyond the 8 hour vininum 9nstaLLat:on <br /> payment. The rty must a/c/(nawiedge :his responsiaili.y ror Me aaaizi=8l bitting by Signature and ;ate etou. <br /> Mame ! U <br /> Ma i t I ng Address <br /> Cr <br /> Jay Phone N <br /> Signature <br /> Date ;i'ti <br /> EN 23 008 <Re .3 ST eg's :lay 5, 1994) <br />